A systematic review of the evidence that swimming pools improve health and wellbeing in remote Aboriginal communities in Australia

Describing skin health and disease in urban-living Aboriginal children: co-design, development and feasibility testing of the Koolungar Moorditj Healthy Skin pilot project

BACKGROUND

Indigenous children in colonised nations experience high rates of health disparities linked to historical trauma resulting from displacement and dispossession, as well as ongoing systemic racism. Skin infections and their complications are one such health inequity, with the highest global burden described in remote-living Australian Aboriginal and/or Torres Strait Islander (hereafter respectfully referred to as Aboriginal) children. Yet despite increasing urbanisation, little is known about the skin infection burden for urban-living Aboriginal children. More knowledge is needed to inform service provision, treatment guidelines and community-wide healthy skin strategies. In this pilot study, we aimed to test the feasibility and design of larger multi-site observational studies, provide initial descriptions of skin disease frequency and generate preliminary hypotheses of association.

METHODS

This project has been co-designed with local (Noongar) Elders to provide an Australian-first description of skin health and disease in urban-living Aboriginal children. In collaboration with an urban Aboriginal Community Controlled Health Organisation (Derbarl Yerrigan Health Service), we conducted a week-long cross-sectional observational cohort study of Aboriginal children (0-18 years) recruited from the waiting room. Participants completed a questionnaire, skin examination, clinical photos, and swabs and received appropriate treatment. We assessed the feasibility and impact of the pilot study.

RESULTS

From 4 to 8 October 2021, we recruited 84 Aboriginal children of whom 80 (95%) were urban-living. With a trusted Aboriginal Health Practitioner leading recruitment, most parents (or caregivers) who were approached consented to participate. Among urban-living children, over half (45/80, 56%) of parents described a current concern with their child's skin, hair and/or nails; and one-third (26/80, 33%) reported current itchy skin. Using a research-service model, 27% (21/79) of examined urban-living participants received opportunistic same-day treatment and 18% (14/79) were referred for later review.

CONCLUSIONS

This co-designed pilot study to understand skin health in urban-living Aboriginal children was feasible and acceptable, with high study participation and subsequent engagement in clinical care observed. Co-design and the strong involvement of Aboriginal people to lead and deliver the project was crucial. The successful pilot has informed larger, multi-site observational studies to more accurately answer questions of disease burden and inform the development of healthy skin messages for urban-living Aboriginal children.

Culturally supported health promotion to See, Treat, Prevent (SToP) skin infections in Aboriginal children living in the Kimberley region of Western Australia: a qualitative analysis

Background

While there are many skin infections, reducing the burden of scabies and impetigo for remote living Aboriginal people, particularly children remains challenging. Aboriginal children living in remote communities have experienced the highest reported rate of impetigo in the world and are 15 times more likely to be admitted to hospital with a skin infection compared to non-Aboriginal children. Untreated impetigo can develop into serious disease and may contribute to the development of acute rheumatic fever (ARF) and rheumatic heart disease (RHD). As the largest organ protecting the body and visible to everyone, skin infections are often unsightly and very painful, therefore maintaining healthy skin and reducing the burden of skin infections is important for overall physical and cultural health and well-being. Biomedical treatments alone will not address these factors; therefore, a holistic, strengths-based approach that aligns with the Aboriginal world view of wellness is required to help reduce the prevalence of skin infections and their downstream consequences.

Methods

Culturally appropriate yarning sessions with community members were conducted between May 2019 and November 2020. Yarning sessions have been identified as a valid method for story sharing and collecting information. Semi-structured, face-to-face interviews and focus groups with school and clinic staff were conducted. When consent was provided, interviews were audio-recorded and saved as a digital recording in a de-identified format; for those yarning sessions not recorded, handwritten notes were scribed. Audio recordings and handwritten notes were uploaded into NVivo software prior to a thematic analysis being conducted.

Findings

Overall, there was a strong knowledge of recognition, treatment, and prevention of skin infections. However, this did not extend to the role skin infections play in causing ARF, RHD or kidney failure. Our study has confirmed three main findings: 1. The biomedical model of treatment of skin infections remained strong in interviews with staff living in the communities; 2. Community members have a reliance and belief in traditional remedies for skin infections; and 3. Ongoing education for skin infections using culturally appropriate health promotion resources.

Interpretation

While this study revealed ongoing challenges with service practices and protocols associated with treating and preventing skin infections in a remote setting, it also provides unique insights requiring further investigation. Bush medicines are not currently practiced in a clinic setting, however, using traditional medicines alongside biomedical treatment procedures facilitates cultural security for Aboriginal people. Further investigation, and advocacy to establish these into practice, procedures and protocols is warranted. Establishing protocols and practice procedures focused on improving collaborations between service providers and community members in remote communities is also recommended.

Funding

Funding was received from the National Health and Medical Research Council [NHMRC] (GNT1128950), Health Outcomes in the Tropical NORTH [HOT NORTH 113932] (Indigenous Capacity Building Grant), and WA Health Department and Healthway grants contributed to this research. A.C.B. receives a NHMRC investigator Award (GNT1175509). T.M. receives a PhD scholarship from the Australian Centre for Elimination of Neglected Tropical Diseases (ACE-NTD), an NHMRC centre of excellence (APP1153727).

Ending rheumatic heart disease in Australia: the evidence for a new approach

■The RHD Endgame Strategy: the blueprint to eliminate rheumatic heart disease in Australia by 2031 (the Endgame Strategy) is the blueprint to eliminate rheumatic heart disease (RHD) in Australia by 2031. Aboriginal and Torres Strait Islander people live with one of the highest per capita burdens of RHD in the world. ■The Endgame Strategy synthesises information compiled across the 5-year lifespan of the End Rheumatic Heart Disease Centre of Research Excellence (END RHD CRE). Data and results from priority research projects across several disciplines of research complemented literature reviews, systematic reviews and narrative reviews. Further, the experiences of those working in acute rheumatic fever (ARF) and RHD control and those living with RHD to provide the technical evidence for eliminating RHD in Australia were included. ■The lived experience of RHD is a critical factor in health outcomes. All future strategies to address ARF and RHD must prioritise Aboriginal and Torres Strait Islander people's knowledge, perspectives and experiences and develop co-designed approaches to RHD elimination. The environmental, economic, social and political context of RHD in Australia is inexorably linked to ending the disease. ■Statistical modelling undertaken in 2019 looked at the economic and health impacts of implementing an indicative strategy to eliminate RHD by 2031. Beginning in 2019, the strategy would include: reducing household crowding, improving hygiene infrastructure, strengthening primary health care and improving secondary prophylaxis. It was estimated that the strategy would prevent 663 deaths and save the health care system $188 million. ■The Endgame Strategy provides the evidence for a new approach to RHD elimination. It proposes an implementation framework of five priority action areas. These focus on strategies to prevent new cases of ARF and RHD early in the causal pathway from Streptococcus pyogenes exposure to ARF, and strategies that address the critical systems and structural changes needed to support a comprehensive RHD elimination strategy.

Mobile phone use and social interactions among caregivers can reduce their ability to provide constant supervision to children at Australian public swimming pools

ISSUE ADDRESSED

Caregivers have a crucial role to play in keeping children safe at public swimming pool facilities, with the most common factor contributing to childhood drowning being a lapse in adult supervision.

METHODS

A mixed methods approach was used to collect observations (n = 301) and interviews (n = 10) with caregivers of children aged 0-10 years at two public swimming pool facilities located in the Perth metropolitan area, Western Australia (WA).

RESULTS

Of the 449 children observed, children aged 6-10 years were significantly less likely to be provided with ideal supervision (26%) compared to younger children aged 0-5 years (62%). Of the caregivers who were using their mobile phone while supervising children (n = 100, 22% of children observed), none provided ideal supervision. Overall supervision levels among caregivers differed with gender, with only 44% (n = 74) of female caregivers providing ideal supervision, compared to 72% (n = 96) of male caregivers. The 10 interviews revealed several themes, including the following: caregivers' perceptions of their supervision responsibilities; barriers to supervision; and awareness and perceptions of a communications campaign designed by the Royal Life Saving WA Branch, known as Watch Around Water (WAW).

CONCLUSION

Caregiver supervision at public swimming pools remains an important issue, particularly the use of mobile phones and its deleterious impact on supervision. The WAW program plays an integral role in educating caregivers of supervision responsibilities. Furthermore, this study adds to the limited evaluation of the WAW program, and thus will help guide future improvements to ensure caregiver supervision is consistent. SO WHAT?: Further research is needed to create strategies to reduce mobile phone use among caregivers, in order to provide safer swimming environments.

Trends in Bacteremia Over 2 Decades in the Top End of the Northern Territory of Australia

Background

Information on the local distribution of bloodstream pathogens helps to guide empiric antibiotic selection and can generate hypotheses regarding the effectiveness of infection prevention practices. We assessed trends in bacterial blood culture isolates at Royal Darwin Hospital (RDH) in the Northern Territory of Australia between 1999 and 2019.

Methods

 Species identification was extracted for all blood cultures first registered at RDH. Thirteen organisms were selected for focused analysis. Trends were examined graphically and using univariable linear regression.

Results

 Between 1999 and 2019, 189 577 blood cultures from 65 276 patients were processed at RDH. Overall, 6.72% (12 747/189 577) of blood cultures contained a bacterial pathogen. Staphylococcus aureus was the most common cause of bacteremia during the first decade, with an estimated incidence of 96.6 episodes per 100 000 person-years (py; 95% CI, 72.2-121/100 000 py) in 1999. Since 2009, S. aureus bacteremia has declined markedly, whereas there has been an inexorable rise in Escherichia coli bacteremia (30.1 to 74.7/100 000 py between 1999 and 2019; P < .001), particularly in older adults. Since 2017, E. coli has been more common than S. aureus. Rates of Streptococcus pneumoniae bacteremia have reduced dramatically in children, while Burkholderia pseudomallei remained the fourth most common bloodstream isolate overall.

Conclusions

 The incidence of S. aureus bacteremia, though high by international standards, is declining at RDH, possibly in part due to a sustained focus on both community and hospital infection prevention practices. Gram-negative bacteremia, particularly due to E. coli, is becoming more common, and the trend will likely continue given our aging population.

Exploring children's participation in commercial swimming lessons through the social determinants of health

ISSUE ADDRESSED

Drowning is a public health challenge, disproportionately impacting children. Social determinants of health (SDH) such as socio-economic disadvantage and geographic isolation increase drowning risk. Swimming and water safety lessons, in part, have reduced drowning in children, while also enabling healthy aquatic participation. Research suggests that some Australian children receive insufficient swimming and water safety education and are not achieving essential skills.

METHODS

A cross-sectional retrospective analysis of swimming and water safety skills achieved by a cohort of children (5-12 years) attending commercial swimming lessons in three Australian states was undertaken. Variables included participant demographics (age, gender, and the SDH of socio-economic status [SES], and geographical remoteness) and skills being taught and achieved. Skills achieved were analysed against the National Swimming & Water Safety Framework and the National Benchmark.

RESULTS

Swim schools were more likely to teach freestyle (87%) and backstroke (83%); and less likely to teach water safety skills like treading water (53%), and survival backstroke (46%). Overall, 40% of 12-year-old children failed to achieve the National Benchmark of 50 metres freestyle, fewer were achieving minimum water safety skills. Children from low socio-economic areas and regional locations were less likely to be achieving 50 metres freestyle. Children in this study were commonly from major cities (94%) and of high socio-economic areas (53%).

CONCLUSIONS

Swimming lessons must incorporate a broad range of swimming and water safety competencies to ensure children have the skills required to reduce drowning, especially for those deemed at increased risk.

SO WHAT

Stakeholders must prioritise holistic drowning prevention education strategies, ensuring all children can access swimming and water safety programs regardless of their socio-economic status or geographical location.

Skin infections in Australian Aboriginal children: a narrative review

Impetigo, scabies, cellulitis and abscesses are common in Australian Aboriginal children. These conditions adversely affect wellbeing and are associated with serious long term sequelae, including invasive infection and post‐infectious complications, such as acute post‐streptococcal glomerulonephritis and acute rheumatic fever, which occurs at the highest documented rates in the world in remote Aboriginal communities.

Observational research in remote communities in northern Australia has demonstrated a high concurrent burden of scabies and impetigo and their post‐infectious complications.

Few data are available for other Australian states, especially for urban Aboriginal children; however, nationwide hospital data indicate that the disparity between Aboriginal and non‐Aboriginal children in skin infection prevalence also exists in urban settings.

The Australian National Healthy Skin Guideline summarises evidence‐based treatment of impetigo, scabies and fungal infections in high burden settings such as remote Aboriginal communities. It recommends systemic antibiotics for children with impetigo, and either topical permethrin or oral ivermectin (second line) for the individual and their contacts as equally efficacious treatments for scabies. β‐Lactams are the treatment of choice and trimethoprim–sulfamethoxazole and clindamycin are effective alternatives for treatment of paediatric cellulitis. Abscesses require incision and drainage and a 5‐day course of trimethoprim–sulfamethoxazole or clindamycin.

Addressing normalisation of skin infections and the social determinants of skin health are key challenges for the clinician. Research is underway on community‐wide skin health programs and the role for mass drug administration which will guide future management of these common, treatable diseases.

Effect of a participatory intervention in women's self-help groups for the prevention of chronic suppurative otitis media in their children in Jumla Nepal: a cluster-randomised trial

Background

Chronic suppurative otitis media (CSOM) causes preventable deafness and disproportionately affects children living in poverty. Our hypothesis was that health promotion in women’s groups would increase their knowledge, attitudes and practices (KAP) regarding ear disease and reduce the prevalence of CSOM in their children.

Methods

We did a cluster randomised trial in two village development committees (VDCs) in Jumla, Nepal. In July 2014, 30 women’s groups were randomly allocated to intervention or control, stratified by VDC and distance to the road. The intervention groups participated in three sessions of health promotion using the WHO Hearing and Ear Care Training Resource Basic Level. The primary outcome was women’s KAP score and the secondary outcome was prevalence of CSOM in their children at 12 month follow-up. Analyses were by intention to treat. Participants and the research team were not masked to allocation.

Results

In June and July 2014 we recruited 508 women and 937 of their children. 12 months later there was no difference in the women’s KAP score (mean difference 0.14, 95% CI − 0.1 to 0.38, P = 0.25) or the prevalence of CSOM in their children (OR 1.10, 95%CI 0.62 to 1.84, P = 0.75) between intervention and control groups. However, overall, there was a significant improvement in the KAP score (mean difference − 0.51, 95% CI − 0.71,to − 0.31, P < 0.0001) and in the prevalence of CSOM from baseline 11.2% to follow-up 7.1% (P < 0.0001).

Conclusions

Health promotion in women’s groups did not improve maternal KAP or reduce prevalence of CSOM. Over time there was a significant improvement in women’s KAP score and reduction in the prevalence of CSOM which may be attributable to our presence in the community offering treatment to affected children, talking to their parents and providing ciprofloxacin drops to the local health posts. More research is needed in low resource settings to test our findings.

Trial registration

Australia and New Zealand Clinical Trial Registry 12,614,000,231,640; Date of registration: 5.3.2014: Prospectively registered.

Electronic supplementary material

The online version of this article (10.1186/s12887-019-1539-y) contains supplementary material, which is available to authorized users.

The role of social determinants of health in the risk and prevention of group A streptococcal infection, acute rheumatic fever and rheumatic heart disease: A systematic review

Background

Rheumatic heart disease (RHD) poses a major disease burden among disadvantaged populations globally. It results from acute rheumatic fever (ARF), a complication of Group A Streptococcal (GAS) infection. These conditions are acknowledged as diseases of poverty, however the role of specific social and environmental factors in GAS infection and progression to ARF/RHD is not well understood. The aim of this systematic review was to determine the association between social determinants of health and GAS infection, ARF and RHD, and the effect of interventions targeting these.

Methodology

We conducted a systematic literature review using PubMed, the Cochrane Library and Embase. Observational and experimental studies that measured: crowding, dwelling characteristics, education, employment, income, nutrition, or socioeconomic status and the relationship with GAS infection, ARF or RHD were included. Findings for each factor were assessed against the Bradford Hill criteria for evidence of causation. Study quality was assessed using a standardised tool.

Principle findings

1,164 publications were identified. 90 met inclusion criteria, comprising 91 individual studies. 49 (50.5%) were poor quality in relation to the specific study question. The proportion of studies reporting significant associations between socioeconomic determinants and risk of GAS infection was 57.1%, and with ARF/RHD was 50%. Crowding was the most assessed factor (14 studies with GAS infection, 36 studies with ARF/RHD) followed by socioeconomic status (6 and 36 respectively). The majority of studies assessing crowding, dwelling characteristics, education and employment status of parents or cases, and nutrition, reported a positive association with risk of GAS infection, ARF or RHD. Crowding and socioeconomic status satisfactorily met the criteria of a causal association. There was substantial heterogeneity across all key study aspects.

Conclusion

The extensive literature examining the role of social determinants in GAS infection, ARF and RHD risk lacks quality. Most were observational, not interventional. Crowding as a cause of GAS infection and ARF/RHD presents a practical target for prevention actions.

Rates of rheumatic heart disease (RHD) are high in disadvantaged populations globally. It results from acute rheumatic fever (ARF), a complication of Group A Streptococcal (GAS) infection. These are described as diseases of poverty, but exactly what components of poverty promote them has been unclear. The aim of this review was to find what specific social and environmental factors are associated with GAS infection, ARF and RHD, and if actions targeting these can reduce disease rates. We did a search of published literature and found 90 relevant articles. Many supported an association between GAS infection, ARF or RHD and crowding, dwelling characteristics, low education level and employment status, poor nutrition and low social class. There was enough evidence to show that crowding and socioeconomic disadvantage increase the risk of GAS infection and ARF/RHD. However, most studies were of fair to poor quality in their ability to answer the research question, and there was little interventional research. This may relate to challenges inherent in intervening to change social determinants of health, but may also suggest lesser research attention to health issues affecting disadvantaged populations. The association between crowding and disease risk strongly supports initiatives to reduce crowding. This should become a key target for ARF and RHD prevention.

Impetigo and scabies - Disease burden and modern treatment strategies

Impetigo and scabies both present different challenges in resource-limited compared with industrialised settings. Severe complications of these skin infections are common in resource-limited settings, where the burden of disease is highest. The microbiology, risk factors for disease, diagnostic approaches and availability and suitability of therapies also vary according to setting. Taking this into account we aim to summarise recent data on the epidemiology of impetigo and scabies and describe the current evidence around approaches to individual and community based treatment.